Provider Demographics
NPI:1679030779
Name:HASTY, KEATON DANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEATON
Middle Name:DANE
Last Name:HASTY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 N COUNCIL RD
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-8000
Mailing Address - Country:US
Mailing Address - Phone:405-485-2112
Mailing Address - Fax:405-485-8661
Practice Address - Street 1:1203 N COUNCIL RD
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-8000
Practice Address - Country:US
Practice Address - Phone:405-485-2112
Practice Address - Fax:405-485-8661
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist